McGuire Laura Stone, Huntoon Kristin, Gerald Brittany M, Stacy Jason D, Ruebenacker Michael P, Kelly Katherine A, Houston Rebecca, Mazzola Catherine A
1Department of Neurosurgery, University of Illinois at Chicago, Illinois.
2MD Anderson Cancer Center, University of Texas, Houston, Texas.
J Neurosurg. 2024 Oct 25;142(3):860-867. doi: 10.3171/2024.6.JNS24515. Print 2025 Mar 1.
FAIR Health-a nonprofit, state-funded database-was created as an independent repository of healthcare claims paid data to address allegations of price fixing. Many insurers have forced physicians to negotiate payments based on Medicare rates, rather than utilizing FAIR Health. The authors' objective was to provide an overview of regional differences in reimbursement rates per several sample neurosurgical Current Procedural Terminology (CPT) codes and to compare Medicare, Medicaid, and usual, customary, and reasonable rates via FAIR Health rate estimates.
The authors compared FAIR Health rates for three common neurosurgical CPT codes: 61510 (removal of bone from skull for removal of upper brain tumor), 22630 (fusion of lower spine bones with removal of disc, posterior approach, single interspace), and 62223 (creation of a brain fluid drainage shunt, ventriculoperitoneal, ventriculopleural, or other terminus), with Medicare and Medicaid reimbursement to evaluate differences in five different regions in the US.
Medicare and Medicaid reimbursement rates were consistently and significantly lower than FAIR Health in-network rates across all three CPT codes evaluated (p < 0.001 for all). Significant regional differences exist per census data in median age, median income, employment rates, and degree of health coverage (p < 0.001, p = 0.002, p = 0.002, and p = 0.001, respectively). Reimbursement estimates were found to have regional variation: Medicare/Medicaid rates were significantly lower than FAIR Health in-network rates for all codes across regions with a region-based interaction for reimbursement for code 62223 (p = 0.020). Medicare and Medicaid rates did not significantly vary across regions.
Inherent differences exist between cities and states, including median income, employment rates, and health coverage. Despite geographic cost practice indices for Medicare and state-specific production of Medicaid, Medicaid/Medicare reimbursement rates did not vary across regions but were consistently and significantly lower than FAIR Health estimates throughout the US. Locale-specific variation in FAIR Health may further indicate a better accounting of regional differences in cost of practice.
公平健康组织——一个由州政府资助的非营利性数据库——被创建为医疗费用赔付数据的独立存储库，以应对价格操纵的指控。许多保险公司迫使医生根据医疗保险费率协商支付费用，而不是使用公平健康组织的数据。作者的目的是概述按几个样本神经外科现行手术操作术语（CPT）代码划分的报销费率的地区差异，并通过公平健康组织的费率估计值比较医疗保险、医疗补助以及通常、习惯和合理费率。
作者比较了公平健康组织针对三个常见神经外科CPT代码的费率：61510（为切除脑上部肿瘤而从颅骨移除骨头）、22630（通过后路单间隙切除椎间盘并融合下脊柱骨）和62223（创建脑积液引流分流管，脑室 - 腹腔、脑室 - 胸膜或其他终端），与医疗保险和医疗补助的报销情况，以评估美国五个不同地区的差异。
在所有三个评估的CPT代码中，医疗保险和医疗补助的报销费率始终显著低于公平健康组织的网络内费率（所有p < 0.001）。根据人口普查数据，在中位年龄、中位收入、就业率和医保覆盖程度方面存在显著的地区差异（分别为p < 0.001、p = 0.002、p = 0.002和p = 0.001）。发现报销估计存在地区差异：对于所有代码，医疗保险/医疗补助费率显著低于公平健康组织的网络内费率，对于代码62223存在基于地区的报销交互作用（p = 0.020）。医疗保险和医疗补助费率在各地区之间没有显著差异。
城市和州之间存在内在差异，包括中位收入、就业率和医保覆盖情况。尽管有医疗保险的地理成本实践指数以及针对特定州的医疗补助数据，但医疗补助/医疗保险的报销费率在各地区之间没有差异，而是在美国各地始终显著低于公平健康组织的估计值。公平健康组织中特定地区的差异可能进一步表明对实践成本的地区差异有更好的核算。
